Recent progress in Glinus oppositifolius research

CONTEXT

Glinus oppositifolius (L.) Aug. DC. (Molluginaceae), a perennial subshrubs herb, grows at low altitudes in the southern part of Taiwan, and is used in traditional Chinese medicine for herpes zoster and herpangina.

OBJECTIVE

This study describes nutritional and therapeutic potential of Glinus oppositifolius and summarizes scientific evidence that supports traditional claims; recent progress in research for this plant is reviewed herein.

MATERIALS AND METHODS

The literature has been retrieved from the web-based online systems including PubMed, Medline, and Google Scholar. The articles related to phytochemistry, pharmaceutical biology and ethnopharmacology have been excluded.

RESULTS AND DISCUSSION

In clinical practice, the plant has been extensively investigated in a broad range of studies to provide scientific evidence for folklore claims or to find new therapeutic uses. The present review may arouse related research and make a more valid display for Taiwanese native medicinal plants.

Not getting lost in translational science: A tool for navigating the pre-implementation phase of multi-site pharmacological clinical trials

BACKGROUND

The compelling need to improve the efficiency of multi-site pharmacological clinical trials has received increasing attention and a number of challenges needing to be addressed have been delineated.

PURPOSE

The present paper discusses one of the challenges, how to avoid a lengthy pre-implementation phase, and proposes the strategy of using a Pre-implementation Timeline "Calculator." The Calculator is a Microsoft Excel worksheet designed to assist investigators in planning for, and completing, the pre-implementation phase of multi-site pharmacological clinical trials in a timely manner.

METHODS

Preliminary data are presented comparing the pre-implementation phase length of pharmacological trials that did (n=3) and did not (n=4) use the Calculator.

RESULTS

The amount of time taken to complete the stage between having a sponsor-approved protocol and the initiation of recruitment at a study site averaged nine months for the Calculator trials compared to 15 months for the Non-Calculator trials. The period between the Investigators' meeting and the initiation of recruitment at a study site averaged two months for the Calculator trials compared to five months for the Non-Calculator trials. An estimate of the site staffing costs associated with the later time frame was calculated for a hypothetical trial conducted at 10 sites. The results revealed that the extra three months were associated with a cost of $388,000.

LIMITATIONS

An important limitation of the present paper is the reliance on a sample of convenience for the Calculator and Non-Calculator trials.

CONCLUSIONS

The Calculator is a free, easily implemented, tool that may provide significant benefits in reducing the time and financial resources required to complete the pre-implementation phase of multi-site pharmacological clinical trials; thus, its more wide-spread use in multi-site pharmacological clinical trials seems warranted.

Dillenia species: A review of the traditional uses, active constituents and pharmacological properties from pre-clinical studies

CONTEXT

Dillenia (Dilleniaceae) is a genus of about 100 species of flowering plants in tropical and subtropical trees of Southern Asia, Australasia, and the Indian Ocean Islands. Until now, only eight Dillenia species have been reported to be used traditionally in different countries for various medical purposes. Out of eight species, D. pentagyna (Roxb), D. indica (Linn.) and D. suffruticosa (Griffith Ex. Hook. F. & Thomsom Martelli) have been reported to be used to treat cancerous growth.

OBJECTIVE

The present review explored and provided information on the therapeutic potential of Dillenia species.

METHODS

Comprehensive and relevant literature on the therapeutic potential of Dillenia species was gathered through electronic databases including Google Scholar, Scopus, PubMed, and books, without limiting the dates of publication.

RESULTS AND CONCLUSION

The review demonstrated that only a few Dillenia species have been proven scientifically for their therapeutic potential in pre-clinical studies, including D. pentagyna, D. indica, D. papuana (Martelli), D. meliosmifolia (Hook. F. Ex. Thomsom) and D. suffruticosa (Griffith Ex Hook. F. & Thomson). A few species of Dillenia have undergone isolation and characterization of compounds with lupeol and betulinic acids having tremendous pharmacological potential. Dillenia species warrant further studies on their therapeutic potential, which may eventually lead to the development of new drug candidates for treatment of various diseases.

Ongoing clinical trials for Vasovagal Syncope: where are we in 2014?

Vasovagal Syncope (VVS) can lead to a markedly diminished quality of life for some patients. While there are many treatments for this condition including physical, mechanical, pharmacologic, and device-based control of heart rate, there are few that have been shown to be effective in randomized clinical trials. In our local experience, we have achieved significant improvement in symptom frequency and quality of life using algorithms based on the data available and on clinical acumen for the majority of patients with VVS. Despite this, there are still many patients who suffer from treatment refractory VVS. Fortunately, there are a number of ongoing clinical trials that are likely to add to our knowledge. Ongoing clinical trials are reviewed to examine new treatment methods for VVS that were listed on public trial registries as of April 15, 2014. Data from these trials should inform future strategies in the care of patients with VVS.

Children with juvenile idiopathic arthritis frequently experience interruptions to their medical therapy

AIM

To study real-life experiences of drug treatment discontinuations and safety in a well-defined cohort of patients with juvenile idiopathic arthritis (JIA), over an eleven-year period in Uppsala County, Sweden.

METHODS

Clinical charts of all incident and prevalent cases of juvenile arthritis were reviewed prospectively by an experienced paediatric rheumatologist. Each patient file was supplemented retrospectively regarding hereditary diseases, clinical data and aspects of pharmacological treatment.

RESULTS

Severe adverse events from methotrexate or biological agents were rare, but 84 occasions of interrupted therapy due to adverse events or inefficacy were identified within 225 treatment periods (37.3%) in the 156 patients (108 girls and 48 boys) studied. The median observation period was 8.6 years after disease onset (minimum 1.33, maximum 17.5 years). Oral and subcutaneous methotrexate caused adverse events in 22.6% of the treatment periods and biological agents in 19.2% (p = 0.71). Discontinuation of treatment periods was equally common for methotrexate (38.7%) and biological agents (33.3%) (p = 0.53).

CONCLUSION

Our study shows a high percentage of interrupted medical therapies, due to adverse events or inefficacy, in children with JIA. Adverse events from methotrexate and biological agents were seldom severe. The results highlight the need for better predictive factors to guide therapy.

Parents' treatment of their children's pain at home: pharmacological and nonpharmacological approaches

INTRODUCTION

During childhood, pain often is experienced on a nearly daily basis. This study focuses on pain alleviation techniques provided by parents, because children's painful experiences are most often treated at home. Hypotheses addressed various factors that can influence use of pain alleviation techniques, including parents' level of catastrophizing about their children's pain, children's age, and conversations with health care professionals.

METHOD

A total of 756 parents of children ages 6 to 17 years completed an online survey regarding pain alleviation including use and effectiveness of pharmacological and nonpharmacological techniques, pain catastrophizing, and questions regarding dialogue with health care professionals.

RESULTS

Parents with increased pain catastrophizing used more pharmacological techniques, and child self-administration of pain alleviation techniques increased with the child's age. Parents were more likely to have spoken with their health care professional about pharmacological techniques.

DISCUSSION

This study provides information that can help health care professionals initiate conversations regarding treatment options and align recommendations with techniques that parents are likely to use, and it can help health care professionals provide supportive alternative recommendations.

Ethanol-derived acetaldehyde: pleasure and pain of alcohol mechanism of action

Acetaldehyde (ACD), the first metabolite of ethanol (EtOH), has been implicated in several actions of alcohol, including its reinforcing effects. Previously considered an aversive compound, ACD was useful in alcoholic’s pharmacological treatment aimed at discouraging alcohol drinking. However, it has recently been shown that EtOH-derived ACD is necessary for EtOH-induced place preference and self-administration, thereby suggesting a possible involvement of ACD in EtOH motivational properties. In addition, EtOH-stimulating properties on DA neurons are prevented by pharmacological blockade of local catalase H₂O₂ system, the main metabolic step for biotransformation of EtOH into ACD within the central nervous system. It was further shown that pretreatment with thiol compounds, like L-Cysteine or D-Penicillamine, reduced EtOH and ACD-induced motivational effects, in fact preventing self-administration of both EtOH and ACD, thus suggesting a possible role for ACD as a biomarker useful in evaluating potential innovative treatments of alcohol abuse. These findings suggest a key role of ACD in the EtOH reinforcing effects. In the present paper we review the role of EtOH-derived ACD in the reinforcing effects of EtOH and the possibility that ACD may serve as a therapeutically targetable biomarker in the search for novel treatments in alcohol abuse and alcoholism.

Current interventions in the management of knee osteoarthritis

Osteoarthritis (OA) is progressive joint disease characterized by joint inflammation and a reparative bone response and is one of the top five most disabling conditions that affects more than one-third of persons > 65 years of age, with an average estimation of about 30 million Americans currently affected by this disease. Global estimates reveal more than 100 million people are affected by OA. The financial expenditures for the care of persons with OA are estimated at a total annual national cost estimate of $15.5-$28.6 billion per year. As the number of people >65 years increases, so does the prevalence of OA and the need for cost-effective treatment and care. Developing a treatment strategy which encompasses the underlying physiology of degenerative joint disease is crucial, but it should be considerate to the different age ranges and different population needs. This paper focuses on different exercise and treatment protocols (pharmacological and non-pharmacological), the outcomes of a rehabilitation center, clinician-directed program versus an at home directed individual program to view what parameters are best at reducing pain, increasing functional independence, and reducing cost for persons diagnosed with knee OA.

Pharmacological treatments for neuropsychiatric symptoms of dementia in long-term care: a systematic review

BACKGROUND

Medications are frequently prescribed for neuropsychiatric symptoms (NPS) associated with dementia, although information on the efficacy and safety of medications for NPS specifically in long-term care (LTC) settings is limited. The objective of this study was to provide a current review of the efficacy and safety of pharmacological treatments for NPS in LTC.

METHODS

We searched MEDLINE, EMBASE, PsychINFO, and the Cochrane Library for randomized controlled trials comparing medications with either placebo or other interventions in LTC. Study quality was described using the Cochrane collaboration risk of bias tool. The efficacy of medications was evaluated using NPS symptom rating scales. Safety was evaluated through rates of trial withdrawals, trial withdrawals due to adverse events, and mortality.

RESULTS

A total of 29 studies met inclusion criteria. The most common medications evaluated in studies were atypical antipsychotics (N = 15), typical antipsychotics (N = 7), anticonvulsants (N = 4), and cholinesterase inhibitors (N = 3). Statistically significant improvements in NPS were noted in some studies evaluating risperidone, olanzapine, and single studies of aripiprazole, carbamazepine, estrogen, cyproterone, propranolol, and prazosin. Study quality was difficult to rate in many cases due to incomplete reporting of details. Some studies reported higher rates of trial withdrawals, adverse events, and mortality associated with medications.

CONCLUSIONS

We conclude that there is limited evidence to support the use of some atypical antipsychotics and other medications for NPS in LTC populations. However, the generally modest efficacy and risks of adverse events highlight the need for the development of safe and effective pharmacological and non-pharmacological interventions for this population.

Recent advances in Duchenne muscular dystrophy

Duchenne muscular dystrophy (DMD), an allelic X-linked progressive muscle-wasting disease, is one of the most common single-gene disorders in the developed world. Despite knowledge of the underlying genetic causation and resultant pathophysiology from lack of dystrophin protein at the muscle sarcolemma, clinical intervention is currently restricted to symptom management. In recent years, however, unprecedented advances in strategies devised to correct the primary defect through gene- and cell-based therapeutics hold particular promise for treating dystrophic muscle. Conventional gene replacement and endogenous modification strategies have greatly benefited from continued improvements in encapsidation capacity, transduction efficiency, and systemic delivery. In particular, RNA-based modifying approaches such as exon skipping enable expression of a shorter but functional dystrophin protein and rapid progress toward clinical application. Emerging combined gene- and cell-therapy strategies also illustrate particular promise in enabling ex vivo genetic correction and autologous transplantation to circumvent a number of immune challenges. These approaches are complemented by a vast array of pharmacological approaches, in particular the successful identification of molecules that enable functional replacement or ameliorate secondary DMD pathology. Animal models have been instrumental in providing proof of principle for many of these strategies, leading to several recent trials that have investigated their efficacy in DMD patients. Although none has reached the point of clinical use, rapid improvements in experimental technology and design draw this goal ever closer. Here, we review therapeutic approaches to DMD, with particular emphasis on recent progress in strategic development, preclinical evaluation and establishment of clinical efficacy. Further, we discuss the numerous challenges faced and synergistic approaches being devised to combat dystrophic pathology effectively.

Disease modifying drugs targeting β-amyloid

At this time there are no effective methods to alter the disease course in Alzheimer's disease. All FDA approved interventions are for symptomatic relief only. However, it is an exciting time as many agents in development have theorhetical potential to impact the disease course. This review discusses some of the agents that have been in clinical trials, particularly those that affect amyloid processing. Some agents have failed while others still provide hope. Since amyloid is the peptide most closely linked to disease pathogenesis, it is possible that some of the anti-amyloid agents will impact the disease progression in a meaningful way.

Newer treatments for fibromyalgia syndrome

Fibromyalgia syndrome is a common chronic pain disorder of unknown etiology. The lack of understanding of the pathophysiology of fibromyalgia has made this condition frustrating for patients and clinicians alike. The most common symptoms of this disorder are chronic widespread pain, fatigue, sleep disturbances, difficulty with memory, and morning stiffness. Emerging evidence points towards augmented pain processing within the central nervous system (CNS) as having a primary role in the pathophysiology of this disorder. Currently the two drugs that are approved by the United States Food and Drug Administration (FDA) for the management of fibromyalgia are pregabalin and duloxetine. Newer data suggests that milnacipran, a dual norepinephrine and serotonin reuptake inhibitor, may be promising for the treatment of fibromyalgia. A double-blind, placebo-controlled trial of milnacipran in 125 fibromyalgia patients showed significant improvements relative to placebo. Milnacipran given either once or twice daily at doses up to 200 mg/day was generally well tolerated and yielded significant improvements relative to placebo on measures of pain, patient's global impression of change in their disease state, physical function, and fatigue. Future studies are needed to validate the efficacy of milnacipran in fibromyalgia.

Pharmacological management of acute bronchiolitis

This article reviews the current knowledge base related to the pharmacological treatments for acute bronchiolitis. Bronchiolitis is a common lower respiratory illness affecting infants worldwide. The mainstays of therapy include airway support, supplemental oxygen, and support of fluids and nutrition. Frequently tried pharmacological interventions, such as ribavirin, nebulized bronchodilators, and systemic corticosteroids, have not been proven to benefit patients with bronchiolitis. Antibiotics do not improve the clinical course of patients with bronchiolitis, and should be used only in those patients with proven concurrent bacterial infection. Exogenous surfactant and heliox therapy also cannot be recommended for routine use, but surfactant replacement holds promise and should be further studied.

Therapeutic approaches to the challenge of neuronal ceroid lipofuscinoses

The Neuronal Ceroid Lipofuscinoses (NCLs) are lysosomal storage diseases (LSDs) affecting the central nervous system (CNS), with generally recessive inheritance. They are characterized by pathological lipofuscin-like material accumulating in cells. The clinical phenotypes at all onset ages show progressive loss of vision, decreasing cognitive and motor skills, epileptic seizures and premature death, with dementia without visual loss prominent in the rarer adult forms. Eight causal genes, CLN10/CTSD, CLN1/PPT1, CLN2/TPP1, CLN3, CLN5, CLN6, CLN7/MFSD8, CLN8, with more than 265 mutations and 38 polymorphisms (http://www.ucl.ac.uk/ncl) have been described. Other NCL genes are hypothesized, including CLN4 and CLN9; CLCN6, CLCN7 and possibly SGSH are under study. Some therapeutic strategies applied to other LSDs with significant systemic involvement would not be effective in NCLs due to the necessity of passing the blood brain barrier to prevent the neurodegeneration, repair or restore the CNS functionality. There are therapies for the NCLs currently at preclinical stages and under phase 1 trials to establish safety in affected children. These approaches involve enzyme replacement, gene therapy, neural stem cell replacement, immune therapy and other pharmacological approaches. In the next decade, progress in the understanding of the natural history and the biochemical and molecular cascade of events relevant to the pathogenesis of these diseases in humans and animal models will be required to achieve significant therapeutic advances.

Latest approaches for the treatment of spasticity and autonomic dysreflexia in chronic spinal cord injury

Two of the most prevalent secondary complications following spinal cord injury (SCI), besides loss of function and/or sensation below the level of injury, are uncontrolled muscle spasticity and hypertensive autonomic dysreflexia. Despite the desires of the SCI community, there have been few advances in the treatment and/or management of these fundamental impediments to the quality of life associated with chronic SCI. Therefore, the purpose of this review is to focus on current drug treatment strategies that alleviate symptoms of spasticity and autonomic dysfunction. Subsequently, looking ahead, we discuss whether individuals suffering from autonomic dysreflexia and/or muscle spasms can take certain compounds that specifically and rapidly block the neurotransmission of pain into the injured spinal cord to get rapid relief for both aberrant reflexes for which painful stimuli below the level of SCI are common precipitants.

Novel insights on diagnosis, cause and treatment of diabetic neuropathy: focus on painful diabetic neuropathy

Diabetic neuropathy is common, under or misdiagnosed, and causes substantial morbidity with increased mortality. Defining and developing sensitive diagnostic tests for diabetic neuropathy is not only key to implementing earlier interventions but also to ensure that the most appropriate endpoints are employed in clinical intervention trials. This is critical as many potentially effective therapies may never progress to the clinic, not due to a lack of therapeutic effect, but because the endpoints were not sufficiently sensitive or robust to identify benefit. Apart from improving glycaemic control, there is no licensed treatment for diabetic neuropathy, however, a number of pathogenetic pathways remain under active study. Painful diabetic neuropathy is a cause of considerable morbidity and whilst many pharmacological and nonpharmacological interventions are currently used, only two are approved by the US Food and Drug Administration. We address the important issue of the 'placebo effect' and also consider potential new pharmacological therapies as well as nonpharmacological interventions in the treatment of painful diabetic neuropathy.

Update on the pharmacological treatment of Alzheimer's disease

Alzheimer's disease (AD) is the most common neurodegenerative disorder. Worldwide prevalence of the disease is estimated at more than 24 million cases. With aging of populations, this number will likely increase to more than 80 million cases by the year 2040. The annual incidence worldwide is estimated at 4.6 million cases which is the equivalent of one new case every seven seconds! The pathophysiology of AD is complex and largely misunderstood. It is thought to start with the accumulation of beta-amyloid (αβ) that leads to deposition of insoluble neuritic or senile plaques. Secondary events in this "amyloid cascade" include hyperphosphorylation of the protein tau into neurofibrillary tangles, inflammation, oxidation, and excitotoxicity that eventually cause activation of apoptotis, cell death and neurotransmitter deficits. This review will briefly summarize recent advances in the pathophysiology of AD and focus on the pharmacological treatment of the cognitive and functional symptoms of AD. It will discuss the roles of vascular prevention, cholinesterase inhibitors and an NMDA-antagonist in the management of AD. It will address the issues thought to be related to the lack of persistence or discontinuation of therapy with cholinesterase inhibitors shown in recent studies and some of the solutions proposed. These include setting realistic expectations in light of a neurodegenerative condition and available symptomatic treatments, slowly titrating medications, and using alternate routes of administration. Finally, it will introduce future therapeutic options currently under study.

Current evidence for osteoarthritis treatments

Osteoarthritis (OA) is the most common form of arthritis and the leading cause of chronic disability among older people. The burden of the disease is expected to rise with an aging population and the increasing prevalence of obesity. Despite this, there is as yet no cure for OA. However, in recent years, a number of potential therapeutic advances have been made, in part due to improved understanding of the underlying pathophysiology. This review provides the current evidence for symptomatic management of OA including nonpharmacological, pharmacological and surgical approaches. The current state of evidence for disease-modifying therapy in OA is also reviewed.

Management of insomnia: update and new approaches

Insomnia is the most prevalent sleep disorder worldwide. A number of studies evaluated the efficacy of pharmacological and nonpharmacological treatment approaches. To obtain long-term effects in the management of chronic insomnia, cognitive-behavioral therapy for insomnia (CBT-I) is the treatment of first choice, encompassing education about sleep and sleep hygiene, sleep restriction, stimulus control, relaxation techniques, and cognitive strategies to combat nocturnal ruminations. Short-term effects can easily be achieved by the administration of hypnotic drugs. Gaining access to all types of treatment can still be considered a problem, especially CBT-I seems to be available only at specialized centers but not in general health care. New approaches to treatment delivery seem to be necessary to provide adequate care for patients who may seek help or have not entered the health care system yet. Internet-based treatment options and stepped-care models might be feasible options for the future. Otherwise, the direct and indirect costs associated with insomnia might further increase for our societies, in addition to the personal impact on aspects of quality of life and impaired daytime functioning for each individual with insomnia. Besides, well-established psychological and pharmacological treatment options, alternative treatments like acupuncture might constitute new nonpharmacological possibilities. Randomized controlled studies are needed to evaluate the efficacy of this and other new approaches to treat insomnia.

A systematic review of the management of autonomic dysreflexia after spinal cord injury

OBJECTIVE

To review systematically the clinical evidence on strategies to prevent and manage autonomic dysreflexia (AD).

DATA SOURCES

A key word search of several databases (Medline, CINAHL, EMBASE, and PsycINFO), in addition to manual searches of retrieved articles, was undertaken to identify all English-language literature evaluating the efficacy of interventions for AD.

STUDY SELECTION

Studies selected for review included randomized controlled trials (RCTs), prospective cohort studies, and cross-sectional studies. Treatments reviewed included pharmacologic and nonpharmacologic interventions for the management of AD in subjects with spinal cord injury. Studies that failed to assess AD outcomes (eg, blood pressure) or symptoms (eg, headaches, sweating) were excluded.

DATA EXTRACTION

Studies were critically reviewed and assessed for their methodologic quality by 2 independent reviewers.

DATA SYNTHESIS

Thirty-one studies were assessed, including 6 RCTs. Preventative strategies to reduce the episodes of AD caused by common triggers (eg, urogenital system, surgery) primarily were supported by level 4 (pre-post studies) and level 5 (observational studies) evidence. The initial acute nonpharmacologic management of an episode of AD (ie, positioning the patient upright, loosening tight clothing, eliminating any precipitating stimulus) is supported by clinical consensus and physiologic data (level 5 evidence). The use of antihypertensive drugs in the presence of sustained elevated blood pressure is supported by level 1 (prazosin) and level 2 evidence (nifedipine and prostaglandin E(2)).

CONCLUSIONS

A variety of options are available to prevent AD (eg, surgical, pharmacologic) and manage the acute episode (elimination of triggers, pharmacologic); however, these options are predominantly supported by evidence from noncontrolled trials, and more rigorous trials are required.

Low molecular weight heparin-induced pharmacological modulation of burn wound healing

Low molecular weight heparin (LMWH) appears to be a promising solution for reducing inflammatory post-burn episodes and results in improved healing. The clinical examination presented here includes patients with burn wounds ranging from 20 to 35% total body surface area (TBSA) who were categorized into two groups, of which one received subcutaneous LMWH treatment (10,000 units/day) and the other acted as control. The process of healing was assessed through regular examination of clinical features such as regression of erythema and oedema, eschar formation, and rate of re-epithelialization. Various studies have demonstrated an increase in levels of serum IL-6 indicating the severity of the morbid condition. In the present investigation, LMWH-treated patients exhibited a faster decline in levels of serum IL-6 (within 12 days) than control. Infiltration of inflammatory cells at the local wound site was assessed through a histological analysis of tissue samples taken on various days during the healing process. The LMWH-treated groups exhibited an organized healing pattern with better remodelling in a shorter duration (28 days), while control patients took more than 28 days for complete healing. A slight correlation was observed with TBSA to the inflammatory process, which subsided in patients treated with LMWH, favourably modulating the events involved in the inflammatory process of burn wound healing.

Clinical pharmacology of old age syndromes

Several syndromes occur in old age. They are often associated with increased mortality and in all there is a paucity of basic and clinical research. The recent developments in the clinical pharmacology of three common syndromes of old age (delirium, urinary incontinence, and falls) are discussed along with directions for future research.